Download Pregnancy - Dermatology

Pregnancy
E
normous changes occur in a woman's body during
pregnancy, and the skin is not exempt. These changes
range from the hardly noticeable right through to the
uncomfortable and even the serious. But every new
mother who holds her healthy baby would probably say
all the physical travails are worth it; in addition, most skin
changes return to normal by the time the new baby is
learning to crawl.
• CHANGES IN COLOR
HYPERPIGMENTATION
The darkening of the skin known as hyperpigmentation is one of the most common skin changes that occurs
during pregnancy. It usually affects only areas of skin that
already have a great deal of pigment, such as the nipples
and the areola that surrounds the nipples, the armpits,
and the genital area.
Fully 90 percent of all pregnant women experience
some pigment changes in these areas. This applies to
women of all races and skin types. In rare instances, skin
may darken all over the body. Such widespread hyperpig-
© Copyright 2000, David J. Leffell. MD. All rights reserved.
Skin and Pregnancy
351
mentation may be the result of a specific hormonal problem, so check with
your doctor if you notice this happening.
It is thought that hyperpigmentation is common in pregnancy because
estrogen and maybe even progesterone stimulate pigment production by
the melanocytes. Since birth control pills contain some of these hormones,
women taking oral contraceptives may also experience some degree of
hyperpigmentation.
THE LINEA NIGRA
The linea nigra is a dark line of skin that develops from the pubic area
to the lower chest area, bisecting the abdomen externally, as the backbone
might be said to bisect the back internally. From the Latin meaning "dark
line," the linea nigra in almost all cases vanishes soon after the baby has
been delivered.
MELASMA
Three out of four pregnant women develop a skin condition called
melasma. Known also as chloasma or the "mask of pregnancy," melasma
affects the cheeks primarily but can occur on the forehead, upper lips, and
chin. The skin in these areas darkens and takes on a masklike quality.
While the actual cause of melasma has yet to be determined, it's clear that
its occurrence has a great deal to do with hormonal fluctuations. Women
who are not pregnant but who are taking birth control pills may also have
to cope with melasma, which is additional proof that levels of estrogen and
progesterone in the blood have a great effect on the skin.
If you have an olive-toned complexion, you are more likely to develop
melasma during a pregnancy. If your melasma is very noticeable, you may
want to try a bleaching cream to minimize it. Although it is considered safe
to use during pregnancy, my rule of thumb is don't try to rock the boat in
the middle of the storm. After pregnancy, the stimulating causes of
melasma will subside and any therapy you start will be easier. This rule
certainly applies to Retin-A, which might be helpful in the management of
melasma but in my opinion should not be used during pregnancy.
Most pregnant women are perfectly happy to forgo anything that might
endanger their pregnancy or their baby when it comes to the appearance
of their skin.
© Copyright 2000, David J. Leffell. MD. All rights reserved.
352
Common Skin Problems
MINIMIZING MElASMA
• Use sunscreen. Ultraviolet radiation will make the pigmentation worse.
• Start with hydrocortisone cream 1% applied twice a day. It is safe to use on the face.
• Discuss with your doctor a regimen that includes Retin-A and/or hydroquinone 4%.
Several brands are available, including some that have sunscreen. (Note: some people are sensitive to hydroquinone bleaching cream. Do a test spot on your inner arm
for three or four days to make sure you don't develop a rash.)
Follow your regimen for at least two months before expecting to see results.
It's afterward that the concern begins. Once your baby is born, and
you're living through those exhausting first months and years, you can
begin to worry about what to do about your hard-earned mask of pregnancy. If you're nursing, you mayor may not want to apply Retin-A, even
though this is probably a low-risk choice in terms of how the topical application will affect your breast milk.
The bad news is that melasma can linger for months or years after it
first develops. While no specific treatment can cure melasma, topical regimens can be helpful. A few patients do respond to the ruby laser. The success rate is generally low, however, and many treatments are needed.
Moreover, the people in whom melasma is the biggest problem-that is,
those with darker skin-run additional risks of side effects with the ruby
laser because it can lead to the loss of underlying normal skin pigment
making the previously dark area appear blotchy and irregular.
• STRETCH MARKS
Stretch marks, known officially as striae gravidarum, occur during
pregnancy due to the slow but steady stretching of the skin's elastin fibers.
Usually they become noticeable only during the third trimester, though
some pregnant women notice them almost right away. Stretch marks occur
most frequently on the breasts, abdomen, hips, and buttocks. It's estimated
that almost 90 percent of pregnant women will have stretch marks.
Darkly pigmented women will notice the stretch mark gradually fade to
a lighter and lighter shade, while white women of various ethnicities will
notice a pinkish line indicating the beginning of a stretch mark. After
© Copyright 2000, David J. Leffell. MD. All rights reserved.
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353
childbirth, the skin where a stretch mark has formed will never fully
recover to its original appearance; instead, it will always remain somewhat
thinned out and noticeable-almost like a scar.
Retin-A may be helpful in minimizing stretch marks after the baby is
born. Some of my patients also report that topical application of vitamin E
helps, and I don't discourage its use. You will also hear, on prepackaged
local-television news spots, that lasers cure stretch marks. Lasers can
remove the redness, but the redness will often fade on its own. As far as
narrowing the width of the stretch marks or thickening the thinned skin,
the verdict isn't in yet. Remember, not all medical "breakthroughs"
reported in the media have been confirmed scientifically. In general, when
it comes to medicine, what applies in the rest of life holds as well: If it
sounds too good to be true, it probably isn't true.
Whatever you decide to do, I advise waiting until after your healthy
baby is born and you've stopped breast-feeding.
• BLOOD VESSELS
Pregnancy can wreak as much havoc on your outer skin as it can on
your blood vessels. This is inevitable because as your circulatory system
adapts to meet the needs of two instead of one, your blood vessels have to
expand rapidly. (It's a bit like expanding the household overnight.) Major
side effects of this great blood vessel expansion are varicose veins and spider nevi.
VARICOSE VEINS
Many women who have never had varicose veins develop them during
pregnancy, due to the rapid and necessary growth of blood vessels and the
increased fluid volume their bodies are carrying. Women who have suffered varicose veins already may find them worsening with each pregnancy. Varicose or dilated veins usually appear in the legs and can be
superficial or deep.
Varicose veins may look like slightly raised blue lines or wavy red
lines. Sometimes they are closely grouped in what is called a star-burst
pattern. While these are superficial veins, they will likely persist after
pregnancy.
The treatment of choice for superficial varicose veins is called sclerotherapy (see chapter 17, "Veins or Vanity") though laser is an option that
© Copyright 2000, David J. Leffell. MD. All rights reserved.
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Common Skin Problems
is pursued more frequently. Results to date are not as predictable as with
sclerotherapy.
SPIDER VEINS
Spider veins can appear anywhere on the body, but they are most common on the arms, neck, and face. Most vanish within two months after
delivery, but about 25 percent persist. For those that don't resolve after
pregnancy (give it some time), laser treatment is now an excellent option.
A fair number of patients come for treatment and tell me that the particular red spot they are concerned about came up during pregnancy three
years earlier and has not resolved. Women are usually satisfied with this
treatment, even though it often takes two or more laser sessions to completely eliminate the growth.
HEMANGIOMAS
Hemangiomas are tightly packed balls of tiny blood vessels that form
bright red bumps, usually dome-shaped and no bigger than the tip of a lead
pencil. Although they are quite red, they do not bleed. A pregnant women
may develop anywhere from a few to a hundred hemangiomas, and these
may grow bigger during the pregnancy. Most of them vanish after birth of
the baby, but if they persist they can be removed by laser therapy or can
be cauterized.
RED PALMS
The red palms of pregnancy (palmar erythema) affect more than 60
percent of white pregnant women. Only 35 percent of black women experience the condition. Palms may be pinkish or bright red, sometimes accompanied by a blue tinge. By the third trimester, the color of the palms is more
pronounced. This condition is not related to pigmentation changes, as commonly thought, but rather is caused by changes in blood flow through the
blood vessels. Palms return to normal once the baby is born.
• SKIN GLANDS
The stimulation of both sweat and oil glands goes way up when you're
pregnant. You can guess what happens. You sweat more, and if you are
© Copyright 2000, David J. Leffell. MD. All rights reserved.
Skin and Pregnancy
355
prone to acne, you may break out more. The only treatment that is considered safe for acne flares during pregnancy is topical erythromycin.
Eccrine, or sweat glands, are needed to regulate the body's temperature. Particularly in the last trimester of pregnancy, eccrine activity
increases dramatically. This may be why women who give birth in the winter can walk around comfortably in only a sweater, and why we pity the
expectant mother who's due in August as she sweats and sweats. Sweating
a lot may be uncomfortable in summer months, but it is not dangerous.
One side effect of this increase in sweat production is that a pregnant
women may develop miliaria, which are minute
whiteheads on the skin triggered by the plugging
of sweat glands.
Sebaceous glands, or oil glands, also
increase their activity during pregnancy, once
again particularly in the last trimester. In addition, a specific group of glands on the skin of the
breasts enlarge during the first few months of
pregnancy and almost always form small bumps
in the nipple area.
• CHANGES IN HAIR AND NAILS
Not only does pregnancy affect every layer
of the skin, it also affects your hair and nails.
HAIR
[
Sweat glands
]
embedded in skin
Hair goes through many changes when
you're pregnant-some good, some not so good.
Women who say their hair feels thicker during pregnancy are not exactly
right, but they're close. The number of hairs that are actually growing at
any given time increases during pregnancy, due to hormonal changes. In
addition, the hair sheds less. So, it's not true that the hair becomes thicker,
there is simply more of it, giving it a thicker, more luxurious texture. This
phase of hair growth is called anagen and continues throughout pregnancy.
Then the next phase in the hair growth cycle, telogen, begins, and the
reverse situation occurs, as the postpartum woman begins to shed more
than she ever has before. In this phase of the hair growth cycle, hairs are
in a resting pattern. Thus, as the anagen hairs fall out, they are not
© Copyright 2000, David J. Leffell. MD. All rights reserved.
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Com m 0 n Ski n Pro b I ems
replaced. The thinning of hair after pregnancy is called telogen effluvium.
It usually lasts for a couple of months as the natural growing and resting
cycle of hair growth re-regulates itself.
In a small number of women, thinner hair may be a permanent effect
of pregnancy. Until recently, there was not a lot to be done for such hair
loss. Now, however, Rogaine, the brand name for minoxidil, is available
over-the-counter and has been proven to stimulate modest hair growth.
Wait until you are finished breast-feeding before using any elective medication.
Hirsutism, also known as excess body hair, can develop when a woman
isn't pregnant, but the increase in and fluctuation of estrogen and other
hormonal levels during pregnancy can contribute to it. Usually, the
increase in hair growth is mild.
NAILS
The increase in hormone production during pregnancy stimulates nail
growth, and during the last months of pregnancy, nails grow particularly
quickly. In addition to an increased growth rate, pregnancy may affect
your nails in a number of other ways.
The irregular production of keratin during pregnancy (sometimes
there's more and other times less) causes nail ridges. Transverse grooving
refers to the new horizontal lines or furrows you may notice running across
the width of your nails. Distal onycholysis is the splitting that may occur
at the tips of your nails, resulting in V-shaped nicks. Dead skin may also
develop underneath your nails during pregnancy in a condition called subungual hyperkeratosis.
Nail problems are difficult for dermatologists to treat at any time.
Unless problems with your nails during pregnancy are particularly bothersome, they're best left alone until after the baby is born.
•
OF MOLES, WARTS, SKIN TAGS,
COLD SORES, ET AL.
Many preexisting skin conditions may worsen during pregnancy. Cold
sores or fever blisters are caused by the herpes virus, which most often
breaks out on the lips. During pregnancy, however, herpes virus infection
may occur in other areas of the body if it was previously contracted there.
© Copyright 2000, David J. Leffell. MD. All rights reserved.
Skin and Pregnancy
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A prime example is genital herpes, which can extend to the anal area. If
you experience an outbreak of genital herpes near the time of your due
date, your doctor will likely schedule you for a Cesarean-section delivery.
Moles, or nevi, tend to increase in size during pregnancy and can
darken in color. New moles may also appear. In most cases, these changes
are natural and benign, and the moles will return to their original size and
color after childbirth. If you notice, however, that other changes accompany the growth of an existing mole or the appearance of a new mole, such
as redness around the area or a raised appearance, consult your physician.
(See chapter 22, "Melanoma.")
Freckles and age spots (liver spots) also tend to grow and change color
during pregnancy. Once again, these changes are normal and present no
danger.
Skin tags can multiply during pregnancy. These occur most frequently
on the neck, under the arms, and in the groin area. The theory is that they
are spawned by excess friction. My guess is that they are also affected by
the increase in a whole host of hormones that have a growth-stimulating
effect. People who are overweight tend to have more skin tags than those
of normal weight.
While skin tags may be annoying, they are harmless. If they remain
after you give birth, they can be easily removed by your dermatologist by
lifting them with a forceps and snipping the small stalk that attaches them
to the skin. This procedure is so quick that local anesthetic isn't even
required in most cases.
Preexisting warts can also grow larger during pregnancy. Whether pregnancy encourages new warts to appear is still not clear. If you have genital
warts and they increase significantly in size, a Cesarean delivery will be
indicated. Plantar warts-those that appear on the soles-can increase in
size and become painful. In this case, there are topical treatments that are
safe and effective to use during pregnancy.
• SKIN CONDITIONS UNIQUE TO PREGNANCY
DERMATITIS
Certain rashes occur only during pregnancy. Most look like common
dermatitis. Many of them mimic acne. Some mimic herpes conditions.
Many forms of dermatitis are common only to pregnancy, and most appear
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Common Skin Problems
as small, itchy, red bumps that are easily treated with topical corticosteroids. The most common eruption of pregnancy is PUPPP, which is short
for Pruritic Urticarial Papules and Plaques of Pregnancy. These bumps,
which usually develop in the third trimester, subside within weeks of delivery, but during pregnancy they typically respond well to topical steroids.
Another variety, autoimmune progesterone dermatitis, is caused by
higher than normal levels of progesterone in the system. It is characterized
by acnelike blemishes on the extremities and buttocks.
ITCHING
Itching, or pruritus gravidarum, makes you feel itchy everywhere.
For pregnant women who experience this mild condition it is usually at its
worst during the last trimester. The one plus to pruritus gravidarum is that
it is invisible-there is no obvious rash. The itching is thought to be caused
by the backup of bile in the bile ducts which can occur during pregnancy.
AN IMMUNIZATION WARNING
If you are thinking of becoming pregnant and know that you have
never had rubella, or German measles, your doctor will recommend a
rubella vaccination. It's important to be vaccinated, since rubella can
cause severe birth defects or miscarriage.
© Copyright 2000, David J. Leffell. MD. All rights reserved.